Articles by JCS

Bone of Contention

Confessions of a Chiropractor

 

Bone of Contention

By

JC Smith, MA, DC

 

3 part series:
1. The State of Health Care in the United States

2. Role of Chiropractic Profession:

The Reason Why Spinal Manipulation Is So Effective.

3. It’s Tough Being a Chiropractor

 

Part 1: The State of Health Care in the United States

Health care in America is in a crisis: in the year 2000, the World Health Organization’s (WHO) analysis of the healthcare delivery systems of each of the 191 nations in the United Nations, the US ranked first in costs although Americans ranked 72nd in overall population health.[1] As well, our health care delivery system ranked 37th in the world, and presently more than 42 million Americans have no health insurance or access, and health insurance premiums may increase this year from 10 to 25% to cover the ever-increasing costs of medical care.

 

Imagine if the US were 72nd in the world in education, or if we were 37th in the world in defense systems? The outcry would be enormous, especially if we were spending over $1.2 trillion for this, the most spent per annum and per capita in the world. Yet when our health care system has such poor ratings, virtually nothing is said by our governmental or medical authorities. Indeed, this glaring problem has been swept under the rug, hoping somehow it will either cure itself or be forgotten by the public.

Studies indicate that traditional medicine as practiced in the US is also a risky business with low quality results, such as the recent report from the Institute of Medicine (IOM) that as many as 98,000 people may die from medical mistakes annually.[2]And that may be a low-ball figure, as other experts believe since many medical mistakes are misinterpreted, unreported or ignored. In fact, other estimates tell us that as many as 230,000 to 280,000 deaths occur annually due to medical mistakes.[3]

As many expert observers now conclude, trying harder will not fix this problem. After a century of control of our health care delivery systems by the allopathic medical profession, one must conclude that this method of health care—drugs and surgery—just hasn’t worked well when we see the high cost, low quality, inaccessibility for millions of uninsured, and low population health ratings. Why every American isn’t just as mad about the dire straits of our health care system as they are about the poor status of our airplane safety is a contention that everyone should be aware of, but for the most part, few seem concerned.

While medical sympathizers may look the other way at these glaring statistics, doctors of chiropractic certainly haven’t. Despite being cast as the ugly stepchild in the medical field, alternative and complementary medicine (CAM) has grown rapidly in the last few decades and chiropractors are the historical leaders in this field. While many perceive DCs as health radicals iconoclastic to medical myths, many refer to them as ahead of their time offering patients an alternative to drugs and ineffective back surgery.

Research from Harvard Medical School by Dr. David Eisenberg showed Americans made almost twice as many office visits to non-MDs than to MDs—a trend that should indicate a growing disenchantment with the present allopathic system.[4] In fact, according to Dr. Eisenberg’s survey, Americans made over 629 million office visits to non-MDs, principally chiropractors, acupuncturists, massage therapists, while patients made only 388 million office visits to MDs. As he concluded, “Maybe ‘alternative’ isn’t so alternative anymore.”

Obviously chiropractic care and other alternative methods will never replace the good work of MDs in emergency rooms, neo-natal care, or in the management of crisis care cases. But not all health problems respond to the allopathic methods of drugs or surgery. Indeed, if all it takes to get well is drugs, with the vast amount of drugs in our society, no one should ever be sick. But a paradox remains: Americans are getting sicker by the day despite all the wonder drugs according to the WHO report.

Obviously much of the public now is not convinced that the answers to their health problems rest with taking more drugs and having more surgeries. CAM practitioners like doctors of chiropractic do have solid footing in helping with some chronic health problems such as the epidemic of back and neck problems, which now is a $75 billion expense annually in the US. In fact, OSHA lists neck pain, low back pain and wrist pain (carpal tunnel syndrome) as the leading repetitive stress injuries in the workplace—all joint disorders that chiropractors have helped with manipulative therapy.

Other than visits to physicians for upper respiratory infections, low back pain itself is the second-leading reason for visits to doctors. Back surgery also is the second-leading reason for surgery in hospitals, back pain is the leading cause of workers’ comp injuries, and is the second-leading cause of disability other than heart disease. While it may not be a killer epidemic, back problems are nonetheless a silent epidemic of massive proportions.

While spinal manipulative therapy (SMT) may have been years ago a bone of contention among some MDs and back surgeons, researchers today are now convinced of the effectiveness of spinal adjustments performed by chiropractors. In fact, the former Agency of Health Care Policy and Research within the US Public Health Service issued a low back pain guideline in 1994 that recommended SMT over back surgery and physical therapeutics. This guideline also stated “Surgery has been found to be helpful in only one in 100 cases of low back problems.” [5]

Other spine researchers agree that SMT is preferable to medical methods. Pran Manga, PhD, medical economist from the Ontario (Canada) Ministry of Health in his studies concluded that chiropractic manipulation and management is superior to other treatments for most acute and chronic back pain patients in terms of effectiveness, cost-effectiveness and patient satisfaction. [6]

The reason for this newly found appreciation for SMT rests with the discovery that, in essence, you don’t slip discs, but you do slip spinal joints. Considering there are 24 small vertebrae bones interconnected by 137 joints, the likelihood of spinal joint dysfunction is now considered the leading cause of back pain. In fact, many researchers now state that the disc theory of back pain is invalid and perpetuates the high cost for back pain treatments due to the mis-diagnosis and mis-treatment of many back pain cases.

A recent article in the New England Journal of Medicine acknowledged that most back pain is “mechanical” in nature, meaning muscle, ligament, and joint dysfunction. According to Dr. Richard Deyo, a leading spine researcher, in his article, “Differential Diagnosis of Low Back Pain,” he showed that “Mechanical Low Back or Leg Pain” constituted 97% of these cases, of which “lumbar strain, sprain” accounted for 70% of these cases; “Non-mechanical Spinal Conditions [disc problems] accounted for “about 1%”; “Visceral Disease” [referred pain from a diseased organ] accounted for 2%.”[7]

Dr. Deyo also criticizes the over-reliance on imaging for low back problems.

“Early or frequent use of these tests [Computed tomography (CT) and MRI] is discouraged, however, because disc and other abnormalities are common among asymptomatic adults. Degenerated, bulging, and herniated discs are frequently incidental findings, even among patients with low back pain, and may be misleading. Detecting a herniated disc on an imaging test therefore proves only one thing conclusively: the patient has a herniated disc.”

 

The US federal guideline also concurred on the misleading interpretation of MRI exams to convey the notion of disc problems as the cause of back pain:

“Degenerative discs, bulging disc and even herniated discs are part of the aging process for the spine and may be irrelevant findings: they are seen on imaging tests of the lumbar spine in a significant percentage of subjects with no history of low back problems. Therefore, abnormal imaging findings seen in a patient with acute low back problems may or may not be related to that individual’s symptoms.[8]

 

This points out the single-most prevalent cause of misdiagnosis in low back pain problems—that is, the overuse of MRI, CT or x-ray images to show disc abnormalities in order to convince patients that some sort of disc problem is the cause of their pain. In fact, as Dr. Deyo and other researchers have repeatedly shown, disc abnormalities are not the cause of back pain; in fact, they are part of the normal aging process. Patients without any back pain often have degenerated or herniated discs, while many patients with back pain have perfectly healthy spines.

This outdated concept is the major pitfall in this medical scenario, and one the public is largely unaware of. Richard Deyo mentions this problem of medical mis-conceptions in low back treatments as part of this problem of back pain: “Calling a [medical] physician a back-pain expert, therefore, is perhaps faint praise--medicine has at best a limited understanding of the condition. In fact, medicines’ reliance on outdated ideas may have actually contributed to the problem.” [9]

The most shocking recommendation in this federal guideline by the AHCPR expert panel focused on back surgery. This expert panel found back surgeries to be costly, based on misleading tests, and were generally ineffective.

“Even having a lot of back pain does not by itself mean you need surgery. Surgery has been found to be helpful in only 1 in 100 cases of low back problems. In some people, surgery can even cause more problems. This is especially true if your only symptom is back pain.”[10]

As Dr. Deyo concluded in his report in the NEJM: “There are wide variations in care, a fact that suggests there is professional uncertainty about the optimal approach. In addition, there is evidence of excessive imaging and surgery for low back pain in the United States, and many experts believe the problem has been ‘overmedicalized.’”[11]

In Part 2, I will explain the role of chiropractic to solve this epidemic of back pain, reduce costs, and to improve worker productivity.


 

Part 2: The Role of Chiropractic

The Reason Why Spinal Manipulation Is Effective

Before the chiropractic explanation will make sense to anyone, it’s important to understand why back surgeries are illogical and ineffective. Research repeatedly has shown the poor results from back surgery, including a recent study by Dr. E. Berger published in Surgical Neurology that showed the high rates of permanent disability from spinal fusions.

One thousand workers’ compensation patients who had undergone lumbar spinal surgery were divided into two groups: one group consisted of 600 patients with single operations, evaluated on average 51 months after surgery; and the second group consisted of 400 with multiple operations, evaluated 38 months postoperatively. The results were stunning, to say the least. 71% of the single-operation group had not returned to work more than 4 years after the operation, and 95% of the multiple-operations had not returned to work. In none of these cases was there a neurological deficit that precluded gainful employment—the failure to return to work being blamed on chronic postoperative pain.[12]

Other medical researchers have also concluded that spinal surgery is ineffective and costly. At the University of Miami Comprehensive Pain and Rehabilitation Center, Dr. H.L. Rosomoff, neurosurgeon, concluded:

 “Further, low back pain in the population at large is not usually a surgical problem, and the chances of there being significant pathology requiring surgical or other forms of intervention may be less than 1% of those affected… Low back pain per se is in the majority not a neurologic problem, an orthopedic problem, or a neurosurgical problem, so that consultation with these groups, unless there are strong suspicions otherwise, has limited value.”[13]

In the AHCPR’s Clinical Practice Guideline, the section on Spinal Fusion clearly summarizes the research.

“There appears to be no good evidence from controlled trials that spinal fusion alone is effective for treatment of any type of acute low back problems in the absence of spinal fractures or dislocation.... Moreover, there is no good evidence that patients who undergo fusion will return to their prior functional level.”[14]

So, if you don’t slip discs and the leading spine researchers do not recommend spinal fusions, what’s the solution? The chiropractic profession stands ready and willing to help with this epidemic for over 100 years. As the nation’s third-largest health profession, millions of American already use DCs for their musculo-skeletal disorders (MSDs), but for many folks the question remains: what do chiropractors do?

To understand why spinal manipulation done by chiropractors is more effective than physical therapy and surgery is to understand the basic anatomy of the spine itself. Unlike what most people have been told by their health care practitioners, the main cause of back is not from “slipped discs” as much as from “slipped joints.”

In the human spine there are 24 vertebrae, 3 pelvic bones, and the skull all interconnected by 137 joints. Whenever someone experiences trauma such as from a fall, car accident, prolonged sitting and standing, or lifting improperly, the spine is subjected to a buckling-type of overload from pressure upon these joints and spinal muscles.

Just as one can sprain the small joints in the bones in an ankle, most back problems are caused from the sprain/strain of these small synovial joints in the spine and the tearing of the spinal soft-tissues around the joint capsule such as muscles, ligaments or tendons. Nerve compression, better known as “pinched nerves,” also can occur when the vertebrae are misaligned, leading to radiating pain down the leg, known as “sciatica” or radiculopathy.

While discs may swell in this process, disc herniation is not the primary cause of low back pain. In fact, most spinal experts now agree that joint dysfunction is the main cause of back pain,[15] which explains why manipulative therapy has always been so effective. This also explains why spinal fusion fails to resolve back pain since the joints are still misaligned. Until these spinal joints are restored to normal motion and stability, back pain is inevitable and re-occurring, which may explain why most back surgery victims never return to work.

Stabilizing an injured back or a weakened back that has finally “gone out” is similar to rehabilitating an injured football knee. The first goal is to restore normal joint play, which is the alignment and flexibility of the joint to restore normal motion. Until this normal joint play is restored via spinal manipulation, there is little chance of recovery by way of drugs, surgery or physical therapy. So, the first goal of the chiropractor is to align the spinal joints with spinal adjustments, which are safe and quite relaxing for most patients.

Once the spinal joints are adjusted, the second phase of care is to stabilize the spine with spinal exercises similar to a football knee injury undergoing rehab to strengthen the damage knee musculature and ligaments. The problem many folks face is the deconditioning process of aging that causes muscles to weaken and hence, more apt to relapse. As comedian Bob Hope once said, “You know you’re getting old when your back goes out more often than you do.”

While most people understand how a car accident may cause a severe whiplash injury in the neck, or sports injuries may cause low back problems, most back problems stem from more innocent and insidious causes. Americans face a larger, more common source of spinal problems—the repetitive stress from our daily jobs. Whether its sitting at a desk in front of a computer all day long, or working as a manual laborer on the flight line, or doing housework bent over for hours on end, our spines are susceptible to many forces, strains, and bad leverage that can cause our spinal joints to misalign.

Whether it’s acute traumatic accidents causing your spinal joints to misalign, or the insidious stress from daily activities, the fact is 80-90% of all adults will suffer with back problems. As well, studies have shown a large percent of children suffer spinal problems that, if uncorrected, may lead to scoliosis and future spinal problems as adults.

Just like with dentistry, it’s a good idea to have your family’s spines check regularly for these joint problems that may lead to back pain, nerve pressure, and spinal curvature. Along with home spinal exercises, your chiropractic spinal care will help you achieve a healthy future and avoidance of this epidemic of back pain.

Spinal adjustments are extremely safe (1 accident per 5.85 million treatments) compared to surgical cases (15,600 strokes/paralysis per million). Mortality rates for SMT are 3 in 10 million cases, whereas deaths from neck surgery are 6,900 per one million.[16] Chiropractors have the lowest malpractice rates of any health practitioner because we work with our hands to correct spinal misalignments.

Plus, a good adjustment instantly relieves pressure on spinal joints, discs and nerves, which explains why over 26 million Americans were extremely satisfied with their chiropractic care last year. Researchers like Gallup recognize that chiropractic care is more patient-friendly than medical care with three times the patient satisfaction rates.[17] Moreover, another Gallup Poll found nine out of ten chiropractic patients felt that their treatment was effective and met or exceeded their expectations.[18]


 

Part 3: It’s Tough Being a Chiropractor

For those of us who have damaged spines from car accidents, sports injuries or just from the normal spills and falls from childhood accidents, chiropractic spinal manipulation is a godsend.

My own experience is typical for many patients who I now treat. While playing football in college, I was tackled by a 230-pound defensive end with a bad attitude. He clobbered me, and when I awoke 20 minutes later from a slight concussion, I couldn’t move my back and I had severe pain going into my arm.

The team doctor diagnosed me with a slipped disc and told me if the drugs didn’t work, I’d need back surgery. Fortunately, my roommate, a former Olympic track athlete, took me to his chiropractor for adjustments. Of course, I was leery of a chiropractor after hearing negative comments from other people during my childhood. Reluctantly I went to see his chiropractor who diagnosed me with a vertebral subluxation in my mid-back. After a week of daily spinal adjustments, I reappeared at the practice field ready to play.

The team doctor came to me, saying, “Well, I guess those drugs I gave you really helped.” “No,” I replied, “I went to a chiropractor instead.” Of course, he hemmed and hawed about that, but finally admitted that chiropractors can help in some cases. Obviously, I was one of those cases by my mere presence on the field again, much to his astonishment.

 

Since then I’ve had two other serious spinal injuries—being thrown from a horse almost broke my neck and starting a lawnmower by pulling the cord threw out my low back. I now have three spinal weaknesses that are permanent and must be managed daily to avoid chronic pain and spinal degeneration. Indeed, most back problems don’t just go away once and for all; they must be managed just like a heart attack, otherwise relapse and spinal arthritis are certain.

After dealing with my own spinal injuries for 30 years as a chiropractic patient and as a chiropractic practitioner for almost 25 years working with nearly 10,000 patients’ back problems, I’ve come to a few conclusions about this epidemic of back pain. These are on-going, mechanical, dynamic problems that, like a trick knee, need daily attention with flexibility and strengthening exercises and periodic adjustments. Considering there are 137 joints between the 24 vertebrae and 3 pelvic bones, it’s easy to understand that most back pain consists of mechanical problems with spinal joints, which explains why SMT has always worked so well to help these conditions.

The hardest part of being a chiropractor is knowing how effective and valuable spinal manipulative therapy actually is despite being the butt of medical slander and ignorance. Sadly, the vilification of chiropractic care in the past has hurt the public as much as doctors of chiropractic by discouraging the use of spinal manipulative therapy, which has now been proven to be the best form of care for 70% of back problems.

Is it little wonder that up to 90% of Americans will suffer from an acute back attack when they’ve been taught to ignore their spinal health care by boycotting SMT? Is it odd that back problems are the leading on-the-job injury when DCs are virtually boycotted by workers’ comp insurance companies because chiropractic care is not as profitable? Is it a mystery that many school kids have scoliosis when they are never adjusted by chiropractors after their childhood accidents and falls, the seeds of spinal distortions?

Indeed, if the AMA’s campaign against the dentists had been as successful, Americans would have a lot more dental problems. Imagine if the medical society had taught patients to ignore their teeth and to boycott dentists? It’s so far fetched that it’s hard to imagine, isn’t it? Imagine the ugly teeth, the crooked smiles, and the gum disease that would have happened if Americans had listened to the medical society disparage the dental profession has they have the chiropractic profession. Indeed, it’s too hard to imagine, but that’s exactly what’s happen with spinal health care in America.

And that’s the biggest frustration about being a chiropractor. Spinal manipulation has always worked to help the vast majority of spinal problems, and the recent research has finally proven the clinical and cost-effectiveness of SMT. No one today who knows of this research could honestly say chiropractic care doesn’t work because the researchers have stated repeatedly that SMT works better than medical methods for the 70% of back problems considered sprains and strains.

Today the issue is about money, pure and simple. Considering back procedures are the third-leading reason for hospital admissions and the average “surgical back” costs $13,990 compared to $800 for an average chiropractic case, and that the annual costs of back problems in the US alone range up to $75 billion, this is a huge money-maker that the medical cartel has no interest in having it decline with spinal manipulative therapy (SMT) or any other alternative method.[19]

The fact that chiropractors are still boycotted by most public hospitals illustrates the fact that hospital administrators have no interest in allowing a “better mousetrap” to exist in their facility when they can extract more money by using expensive medical methods instead. They ignore the research and recommendations by the US Public Health Service that have shown that SMT is faster, safer, and less expensive than medical methods. Indeed, they’re willing to deny patients their freedom of choice in order to profit by using back surgeries instead of SMT.

The illegal boycott of chiropractors in public hospitals also denies patients their freedom of choice—an essential element of our free enterprise system. By denying patients a choice, it creates a monopolistic situation characterized by poor services at high costs. Imagine if you had but one choice in regards to the house you buy, the car you drive, where you worked, who you voted for, or any of the important issues in our lives. We wouldn’t tolerate the lack of choice in our lives, but in health care, patients are routinely denied their freedom to choose their own health care providers.

So, what would you say to a failed back surgery victim who has been misdiagnosed with the “slipped disc” diagnosis, mistreated by spinal fusions that have been criticized by all the leading spine authorities as ineffective, and misinformed as to their legal right of “informed” consent that is suppose to inform you as to all risks and alternatives?

This is a crime that leaves many patients disabled by an unnecessary back surgery that was ineffective because failed to correct the underlying cause of the back pain (joint dysfunction), and was perpetuated by doctors and surgeons who knowingly lie to patients about chiropractic care as an effective and appropriate method for low back pain. It is also perpetuated by HMOs that deny chiropractic coverage, and by hospitals that refuse to have chiropractors on their staff. Again, it’s all about money—not science or ethics.

Nowadays with the billions of dollars at stake in healthcare, many decisions that affect your health care are not a consideration of helping the patient get to right type of doctor for the best care available. Today, it’s all about money. Indeed, if patients had unobstructed access to DCs, the epidemic of back problems would be decreased, work disability would improve, fewer spinal surgeries would be done, less expenses for hospitalization, and fewer people would have the acute back attacks that 90% of adults now suffer with.

With the recent plethora of research and government recommendations for SMT for this epidemic of back problems, it makes no sense whatsoever to not include chiropractic care in every health care system for all Americans. Medicare has included chiropractic care since the early 1970s, the military health services now includes chiropractic care, the VA will soon expand its services to include chiropractors, and even the federal BC/BS program now covers chiropractic care.

So, when will the public hospitals in Macon and middle Georgia include a chiropractor on staff? When will Mercer Medical School employ a DC to teach alternative health care methods to aspiring medical students? When will workers’ comp insurance companies refer low back pain patients to chiropractors as the first line of treatment as the US Public Health Service suggests? Indeed, when will the American health care delivery system put aside its economic and political bias and incorporate alternative health care methods to help sick folks get well using natural methods?

If America hopes to improve upon its dismal rating of 72nd in terms of population health and first in expenses according to WHO, health professionals need to think out of the medical box of drugs and surgeries. Chiropractic care has been proven to be more successful with the epidemic of back and neck pain problems, but the medical boycott of this leading alternative health care profession has only perpetuated the failing statistics of American health care delivery system, increased costs and increased disability. Indeed, after a century of drugs and surgery, it’s time to think out of the medical box to solve the many health problems facing Americans, and chiropractic care stands ready and willing to help.

 

 

 

 



[1] WHO: The World Health Report 2000—Health systems: Improving performance. June 21, 2000.

[2] Institute of Medicine, To Err is Human: Building a Safer Health System (Washington: National Academy Press, 1999).

[3] Schuster M, McGlynn E, Brook R. How good is the quality of health care in the United States? Milbank Quarterly 1998; 76:517-563.

[4] Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States -- prevalence, costs, and patterns of use. N Engl J Med 1993;328:246-252.

[5] Bigos S et al. (1994) Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14, AHCAPR Publ. No., 95-0642, Rockville MD; Agency for Health Care Policy and Research, Public Health Service, US Dept. of Health and Human Services.

[6] Manga, P and Angus, D. “Enhanced chiropractic coverage under OHIP as a means of reducing health care costs, attaining better health outcomes and achieving equitable access to select health services.” Working paper, University of Ottawa, 98-02.

[7]Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001 Feb 1;344(5):363-70


[8] S. Bigos, et al., “Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14,” U.S. Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 95-0642, Rockville, MD: Dec. 1994.

[9] Deyo, RA. Low -back pain., Scientific American, pp. 49-53, August 1998.

[10] Bigos S. ibid.

[11] Deyo RA, Weinstein JN, ibid.

[12] Berger E. Later postoperative results in 1000 work related lumbar spine conditions. Surg. Neurol 2000 Aug:54(2)101--6

[13] Rosomoff HL, Rosomoff RS Low back pain. Evaluation and management in the primary care setting. Med Clin North Am 1999 May; 83(3):643-62

[14] Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. AHCPR Publ. No 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services, December 1994, pp. 90.

[15] Seaman, D. Joint complex dysfunction, a novel term to replace subluxation/subluxation complex. Etiological and treatment considerations. J. Manip Physiol Ther 1997, 20:634-44.

[16] P. Shekelle, et al, “The Appropriateness of Spinal Manipulation for Low Back Pain.” RAND Corporation Report, Santa Monica, Calif., 1992.

[17] Gallup Organization, Demographic Characteristics of Users of Chiropractic Services. Princeton, NJ: Gallup, 1991

[18] The Gallup Organization. Demographic Characteristics of Users of Chiropractic Services (Princeton, NJH: The Gallup Organization, 1991)

[19] Mushinski M. Average hospital charges for medical and surgical treatment of back problems: United States, 1993. Statistical Bulletin. Metropolitan Life Insurance Co., Health and Safety Division, Medical Dept., April-June 1995.

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